Nonsteroidal antiinflammatory drugs in rheumatoid arthritis and osteoarthritis. Support for the concept of “responders” and “nonresponders”

Objective. A range of functional, biochemical, and psychological indicators was used to test the concept of “responders”/“nonresponders” and to seek predictors of response to 2 nonsteroidal antiinflammatory drugs in 9 patients with rheumatoid arthritis (RA) and 11 with osteoarthritis (OA). Methods. In a balanced, randomized, doubleblind, latin-square study design that involved four 4- week treatment periods, patients received ketoprofen or piroxicam (each for 2 of the 4 periods). Clinical and laboratory responses (pain, tenderness, swelling, patient and physician global assessments, acute-phase protein levels, and disability) were assessed in the last 2 weeks of each period. Responders were those who showed >30% improvement in at least 5 of 7 measures of disease activity. Mood was also assessed. Results. At baseline, variables were higher in RA than in OA patients. The drugs produced clear improvements in patients' visual analog scale scores, physicians' overall assessments, and patients' responses to the McGill Pain Questionnaire, as well as plasma prostaglandin concentrations. In patients with either RA or OA, responders could be distinguished from nonresponders; about one-third of patients were unambiguous responders. In RA, there were responder nonresponder differences in lymphocyte counts, erythrocyte sedimentation rate (ESR), and levels of tumor necrosis factor α, but no differences were seen in OA patients. However, caution in interpretation of the data is necessary because of the small number of patients. Responders had improved mood scores compared with nonresponders in both disease groups. Baseline ESR and white blood cell counts were correlated with responder status in RA patients. Conclusion. This study provides support for the responder/nonresponder concept. It also indicates that in RA, pretreatment ESR and lymphocyte counts are possibly useful indicators of therapeutic response.     

“Homozygosity” for the HLA–DR shared epitope contributes the highest risk for rheumatoid arthritis concordance in identical twins

Objective. To assess the contribution of HLA–DRB1 alleles in determining rheumatoid arthritis (RA) concordance in monozygotic twins. Methods. Ninety-one monozygotic twins pairs in which at least 1 twin was affected were typed for HLA–DRB1 using both serologic methods and polymerase chain reaction amplification with sequence-specific oligonucleotide hybridization. The role of DR4 and of the shared epitope in disease concordance was investigated. Relative risks (RR) with 95% confidence intervals were determined. Results. Increased concordance for RA was observed in both DR4 positive and shared epitope positive pairs (RR 3.4 and 3.7, respectively). A 5-fold risk for RA concordance was seen in twins who were “homozygous” for the shared epitope, compared with those negative for the shared epitope. Conclusion. In the absence of the shared epitope, RA concordance in monozygotic twins is rare. In contrast, “homozygosity” for the shared epitope is the most important factor in determining RA concordance.     

Hand ultrasound: Comparative study between “no rhupus” lupus erythematosus and rheumatoid arthritis

Abstract

Objective. To compare hand US between systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients.

Methods. Hands (1st–5th metacarpophalangeal [MCP] and 1st–5th proximal interphalangeal [PIP] joints) and wrists (radiocarpal and distal radioulnar joints) of 62 “no rhupus” SLE and 60 RA patients were compared through US (linear probe, 6–18 MHz). The findings were compared to clinical, functional, serological outcomes, and disease activity indices.

Results. 2108 and 2040 joint recesses were evaluated in SLE and AR patients, respectively. Synovitis was found in 46.8% and 75% of wrists, 83.9% and 86.7% of MCPs and 58.1% and 70% of PIPs in the SLE and RA groups, respectively. More significant US findings were found in RA group. Greater values of synovitis (mm) in RA group were only found in the joint recesses of wrist (p < 0.001–0.002). In SLE group, US findings were associated with “puffy hands,” Health Assessment Questionnaire score and dynamometry. Twenty-two SLE patients (35.5%) had erosion in any of joints studied. SLE patient subgroup with US erosion was associated with hematological involvement and Jaccoud's arthropathy.

Conclusions. US of “no rhupus” SLE and RA patients is different, especially in wrists. In SLE patients the clinical variable most associated with US findings was “puffy hands.”     

A 15-year follow-up study on the outcome in patients with early rheumatoid arthritis

Abstract

This study aimed to investigate the natural course of early rheumatoid arthritis (RA) after treatment for 15 years based on the present data of patients who had been enrolled in a 1 year study of early RA conducted by the Japan Rheumatism Foundation in 1981 and 1982. An examination form was mailed to each doctor who had participated in the previous study requesting them to record the present data of the patients. The patients were requested to fill out the AIMS2 questionnaire. Patients had been randomly assigned into three treatment groups: those treated with gold, with d-penicillamine and without slow acting antirheumatic drugs (SAARDs). Information was obtained concerning 74 of 161 patients who had completed the previous 1 year study. Clinical remission was observed in 20 of 74 patients. The current status of RA by physician’s assessment was reported to be well controlled in 32 of 48 cases (66.7%); however, no remarkable improvement was seen in erythrocyte sedimentation rate (ESR, and the number of painful joints compared with the values at entry 15 years previously. Radiographical stages showed progression and the average score of AIMS2 had deteriorated in most cases. High ESR, progression of joint damage and positive rheumatoid factors at the early stage of RA were suggested to be factors relating to QOL deterioration. These results suggest that it would be difficult to modify the natural course of RA by currently used treatment strategies with SAARDs.     

Decreasing incidence and prevalence of rheumatoid arthritis in pima indians over a twenty-five—year period

Objective. To evaluate temporal trends in the incidence of rheumatoid arthritis (RA). Methods. Incident cases of RA were identified among a population-based cohort of Pima Indians in Arizona over the period 1965–1990. Results. Among 2,894 subjects, 78 incident cases of RA were identified. The age-adjusted incidence declined by 55% in men (P_trend = 0.225), and by 57% in women (P_trend = 0.017) after controlling for oral contraceptive or estrogen use and for pregnancy experience. During the same period, age-adjusted prevalence rates of active RA decreased by 29% in men (P_trend = 0.63) and by 40% in women (P_trend = 0.02). Fewer than 17% of subjects with known RA were taking slow-acting antirheumatic drugs (SAARDs) in 1990. Conclusion. The decrease in incidence and prevalence of RA in this population over such a short period implicates the involvement of an environmental factor(s), other than exogenous estrogens, in the pathogenesis of the disease. However, the possibility that the observed decrease might be explained by an increased use of SAARDs in subjects with RA cannot be excluded.     

Impact of initial aggressive drug treatment with a combination of disease‐modifying antirheumatic drugs on the development of work disability in early rheumatoid arthritis: A five‐year randomized followup trial

Objective

To compare the efficacy of therapy with a combination of disease‐modifying antirheumatic drugs (DMARDs) versus therapy with a single DMARD in the prevention of work disability in patients with early rheumatoid arthritis (RA).

Methods

In the Finnish Rheumatoid Arthritis Combination Therapy trial, 195 patients with recent‐onset RA were randomly assigned to receive either combination therapy with DMARDs (sulfasalazine, methotrexate, hydroxychloroquine) plus prednisolone or single therapy with a DMARD with or without prednisolone. After 2 years, the drug treatment strategy was no longer restricted. At baseline, 162 patients (80 in the combination‐treatment group and 82 in the single‐treatment group) were still working or at least available for work. After 5 years of followup, data on all sick leave and retirement were obtained from social insurance registers or case records. The main outcome for each patient was the cumulative duration of all sick leaves and RA‐related disability pensions, divided by the observation period during which the patient was not retired because of another disease or because of age.

Results

The cumulative duration of work disability per patient‐observation year was significantly lower in those randomized to combination therapy than in those randomized to single therapy: median 12.4 days (interquartile range [IQR] 0–54) versus 32.2 days (IQR 6–293) (P = 0.008, sex‐ and age‐adjusted P = 0.009). This was mainly due to the difference in sick leaves (i.e., work disability periods ≤300 days): median 11.7 days (IQR 0–44) per patient‐observation year in those treated with combination therapy and 30.0 days (IQR 6–68) in those treated with single therapy (P = 0.002). No statistically significant difference was seen in RA‐related disability pensions.

Conclusion

Aggressive initial treatment of RA with a combination of DMARDs improves 5‐year outcome in terms of lost productivity in patients with RA of recent onset.

     

Serious infection during etanercept,infliximab and adalimumab therapy for rheumatoid arthritis: A literature review

The purpose of this review is to establish whether there is a significantly increased incidence of serious infections during treatment for rheumatoid arthritis (RA) with etanercept, infliximab or adalimumab, to determine the background risk of serious infection in RA patients without treatment with any biological therapy and to ascertain which organisms are involved in serious infections in RA patients while being treated with etanercept, infliximab or adalimumab. Randomised controlled trials (RCTs), meta‐analyses of RCTs, Cochrane reviews, national registry articles and case reports were identified using PubMed/MEDLINE, The Cochrane Library and Google Scholar. The medical subject heading “rheumatoid arthritis” was combined with “serious infection” or “infection” or “adverse drug events” with each of the three reference biological therapies separately: etanercept, infliximab and adalimumab. These electronic searches were limited to human studies, adult studies, those published in the last 10 years (2004–14) and in the English language. Studies which involved the tumor necrosis factor‐α inhibitors certolizumab pegol or golimumab were excluded. The background risk of serious infection appears to be approximately two‐fold more than non‐RA patients before any treatment with biological therapy. The national registries, which may represent the typical RA patient more accurately than clinical trials, suggest a small but significantly increased incidence of serious infection ranging 1.2–2.78 times that of control (treatment with methotrexate). Mycobacteria spp., Staphyloccus aureus, Listeria monocytogenes, Varicella zoster virus and Leishmania species (spp.) repeatedly appear in the case report literature and should be in the mind of the clinician faced with a serious infection in a RA patient with an unknown pathogen who is being treated with either etanercept, infliximab or adalimumab.     

Application of the “Hybrid Approach” to Chronic Total Occlusion Interventions: A Detailed Procedural Analysis

Objective

To assess the outcomes of the “hybrid” approach to chronic total occlusion (CTO) percutaneous coronary interventions (PCIs).

Background

The “hybrid approach” to CTO PCI advocates appropriate and early change of crossing strategy to maximize success, safety, and efficiency.

Methods

We prospectively recorded and analyzed detailed step‐by‐step procedural data in 73 consecutive CTO PCI cases performed by a single operator between July 2011 and August 2012.

Results

Technical success was achieved in 66 of 73 cases (90.4%). Mean patient age was 65 ± 7 years, and 30% had prior coronary artery bypass surgery. Dual injection was used in 78%. The primary approach was retrograde in 9 cases (12.5%) and antegrade in 64 cases (87.5%), of whom 25 cases (39.1%) underwent retrograde attempt after failed antegrade approach. The initial crossing approach was successful in 40 cases (54.8%), but 32 cases (44%) required 3.6 ± 1.4 approach changes (range 2–7). Antegrade wire escalation, antegrade dissection/reentry, and retrograde crossing were utilized in 97.2%, 46.6%, and 46.6% of cases, respectively. Among successful cases, the final CTO crossing technique was antegrade wire escalation in 50.0%, antegrade dissection/reentry in 24.2%, and retrograde in 25.8%. The mean procedure time, fluoroscopy time, and air kerma radiation exposure until CTO crossing or stopping the procedure were 66 ± 55 minutes, 25 ± 23 minutes, and 2.3 ± 1.9 Gray, respectively. Three patients (4.1%) had a major complication.

Conclusion

In the “hybrid approach” to CTO PCI, changes in crossing strategy were needed in approximately half the cases, resulting in high success and low complication rates. (J Interven Cardiol 2014;27:36–43)

     

Doppler echocardiography distinguishes between physiologic and pathologic “silent” mitral regurgitation in patients with rheumatic fever

Background: The diagnosis of rheumatic fever is based on physical findings (major) and supporting laboratory evidence (minor) as defined by the Jones criteria. Rheumatic carditis is characterized by auscultation of a mitral regurgitant murmur. Doppler echocardiography, however, may detect mitral regurgitation when there is no murmur (“silent” mitral regurgitation), even in normal individuals. Hypothesis: The hypothesis of this study was that physiologic mitral regurgitation can be differentiated from pathologic “silent” mitral regurgitation by Doppler echocardiography. Methods: The study group consisted of 68 patients (2–27 years) with normal two-dimensional imaging and Doppler evidence of mitral regurgitation but no murmur. Patients with rheumatic fever (n = 37) met Jones criteria (chorea in 20, arthritis in 17). Patients without rheumatic fever (n = 31) were referred for innocent murmur (n = 7), abnormal electrocardiogram (n = 13), and chest pain (n = 11). Echoes were independently reviewed by two cardiologists blinded to the diagnosis. Pathologic mitral regurgitation was defined as meeting the following four criteria: (1) length of color jet > 1 cm, (2) color jet identified in at least two planes, (3) mosaic color jet, and (4) persistence of the jet throughout systole. Jet orientation was also noted. Results: Using the above criteria, there was agreement in echo interpretation of pathologic versus physiologic mitral regurgitation in 67 of 68 patients (interobserver variability of 1.5%). Pathologic regurgitation was found in 25 (68%) patients with rheumatic fever but in only 2 (6.5%) patients without rheumatic fever (p<0.001). The specificity of Doppler for detecting pathologic regurgitation was 94% with a positive predictive value of 93%. The color mitral regurgitant jet was posteriorly directed in all 25 patients with rheumatic fever. Conclusion: Pathologic “silent” mitral regurgitation of rheumatic fever can be distinguished from physiologic mitral regurgitation using strict Doppler criteria, particularly when the jet is directed posteriorly. These data support the use of Doppler echocardiography as a minor criterion for evaluating patients with suspected rheumatic fever.     

Rheumatoid nodules do not predict response to treatment with slow-acting anti-rheumatic drugs

Summary Rheumatoid nodules have been associated with a poor long-term prognosis. We investigated whether they predict a poor response to treatment with slow-acting anti-rheumatic drugs (SAARDs). Two hundred and twenty-eight patients with rheumatoid arthritis (RA) were treated for six months with a SAARD. Clinical and laboratory assessments of disease activity were made initially and after 6 months' treatment. Patients were divided into two groups according to the presence or absence of nodules at entry. Twenty-one % had nodules before treatment but their response was no different to patients without nodules (79%), both groups showing improvements in all variables. Males were more likely to develop nodules and had a relative risk of 1.7. High titres of rheumatoid factor correlated with nodules and no sero-negative patients had nodules. We conclude that nodules are not predictive of poor response to treatment with a SAARD, despite their presence being associated with a poor long-term prognosis. One possible implication is that SAARDs themselves, despite an early response, may not effect long-term outcome.     

Assessment of Efficacy and Safety of Combining “Paclitaxel” Eluting Balloon and “Limus” Eluting Stent in the Same Lesion

Objectives

To assess the safety and efficacy of combining drug‐eluting balloon (DEB) and drug‐eluting stents (DES) in the same coronary lesion.

Background

Use of DEB may not always produce optimal results or even result in dissection, compelling the operators to consider bailout stenting with bare metal stents (BMS). However, BMS may not be ideal in patients who have significant risk‐profile for restenosis. We have opted for DES over BMS in such situations and present our follow‐up data.

Methods

Between 2009 and 2011, 46 patients (57 lesions) requiring bailout stenting following DEB use were treated with second‐generation DES. All patients had at‐least one or more risk‐factors that made them vulnerable for restenosis (diabetes, chronic kidney disease, previous in‐stent restenosis [ISR], and/or long diffuse lesions ≥30 mm).

Results

Of the 57 lesions, 34 (60%) were previous ISR. The mean length of the DEB was: 36.2 ± 5.6 mm. All patients had TIMI‐3 flow post PCI with no in‐lab complications. At median follow‐up of 12.3 months (interquartile range [IQR]: 7.5–18.1), the rates target lesion revascularization (TLR) and target vessel revascularization (TVR) were 3 (5.3%) and 4 (7%), respectively. One patient had died 3 months following treatment. There were no episodes of myocardial infarction, definite or probable stent thrombosis. The major adverse cardiovascular events (MACE) rate defined as cardiac‐death, MI, and TVR occurred in 11% of patients.

Conclusion

The results from this novel strategy of combining “Paclitaxel” eluting balloon and “Limus” eluting stent in a same lesion are encouraging. Dual drug‐elution acting on two different pathways may provide potential synergy that may explain the favorable outcome. (J Interven Cardiol 2013;26:259–263)

     

HLA—DRB1 genes and disease severity in rheumatoid arthritis

Objective. To examine the effect of alleles encoding the “shared”/“rheumatoid” epitope on rheumatoid arthritis (RA) disease severity in patients who participated in the minocycline in RA (MIRA) trial. Methods. Of 205 patients with a week-48 visit, blood was available for typing of HLA-DRB1 and HLA-DQB1 in 174 (85%) and successfully completed in 169 (82%). Baseline erosions were used to assess disease severity and new erosions at the last visit served as a proxy for progression. Results. At baseline, there was no association between the presence of erosive disease or rheumatoid factor status and the dose of rheumatoid epitope (homozygous, heterozygous, none) or the specific alleles identified. At the final visit, a gradient was observed for the 3 allelic subgroups (and their gene doses) in the occurrence of new erosions among the Caucasian placebotreated, but not the minocycline-treated, patients. A treatment group/HLA-DR4 epitope interaction was demonstrated in multivariate analyses. Approximately two-thirds of African-American patients did not have the rheumatoid epitope. Conclusion. HLA-DRB1 oligotyping may be useful in predicting the progression of disease in some Caucasian patients. Our study corroborates the infrequency of the epitope among African-American patients with RA.     

“Moderate” and Hard Drug Users among College Students: A Study of their Drug Use Patterns and Characteristics *

Abstract This study compared the drug use patterns and characteristics of a group of noninstitutionalized “moderate” drug users with those of a hard drug user group-One hundred college students were administered a drug data sheet which served to categorize Ss into “moderate” and hard drug-taking groups as well as to determine their individual drug use patterns. Results indicated the two groups were equated on most social and demographic variables. The “moderate” users differed significantly from the hard users along many drug-use dimensions. Hard users appear to be considerably more “friend-dependent” for their drug information and in their motivation to take drugs than are the “moderate” users. Alcoholic beverage consumption among hard users’parents was significantly greater than “moderates” parents. The implication of these findings, as well as others, are discussed along with some suggestions for further research.     

Long‐Term Outcomes of Total Parathyroidectomy With or Without Autoimplantation for Hyperparathyroidism in Chronic Kidney Disease: A Meta‐Analysis

The aim of the present study was to compare total parathyroidectomy without autotransplantation (TPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT) for renal hyperparathyroidism (RHPT) with respect to long‐term outcomes. A literature search was undertaken using Medline and EMBASE from inception to December 2013. Data were analyzed using Review Manager version 5.0. A total of seven cohort studies comprising 931 patients were identified. Compared with TPTX + AT, patients in the TPTX group have lower “recurrence” (odds ratio (OR) 0.08, confidence interval (CI) 0.03 to 0.21; P < 0.00001), lower “recurrence or persistence”(OR 0.11, 95% CI 0.05 to 0.25; P < 0.00001), lower “requiring reoperation because of recurrence or persistence” (OR 0.17, CI 0.06 to 0.54; P = 0.002), and higher “hypoparathyroidism” (OR 2.97, CI 1.09 to 8.08; P = 0.03). None of the patients in these seven studies were recorded as having severe hypocalcemia or adynamic bone disease. Compared with TPTX + AT, TPTX is associated with lower “requiring reoperation because of recurrence or persistence” and without severe hypocalcemia or adynamic bone disease.     

Stroke Risk Stratification in a “Real‐World” Elderly Anticoagulated Atrial Fibrillation Population

Stroke Risk Stratification . Introduction: Appropriate stroke risk stratification is essential to ensure suitable tailoring of antithrombotic therapy. The objective of this study was to assess the predictive value of stroke risk classification schemes and to identify patients with atrial fibrillation (AF) who are at substantial risk of stroke despite optimal anticoagulant therapy, in a “real world” consecutive elderly AF cohort. Methods: Six hundred and sixty‐two consecutive AF patients (mean [SD] age 74 [7.7] years; 36.1% female) referred to the Anticoagulation Clinic of the Azienda Ospedaliera Careggi of Florence, Italy, were included and followed‐up for a mean 3.6 ± 2.7 years for the incidence of thromboembolic (TE) events. The ability of the new CHA₂DS₂‐VASc schema to predict TE was compared with other contemporary stroke risk schema (including CHADS₂, NICE 2006, ACC/AHA/ESC 2006, and ACCP 2008), by determining the c‐statistic. Results: Univariate predictors of TE events were female gender (odds ratio 1.9; 95%CI [confidence intervals] 1.01–3.70) and previous stroke/transient ischemic attack (TIA)/TE (OR 5.6; 95%CI 2.70–11.45), although after adjustment only previous stroke/TIA/TE was an independent predictor of TE (OR 5.5; 95%CI 2.68–11.31; P = 0.0001). All stroke risk schema had modest discriminating ability, with c‐statistics ranging from 0.54 (atrial fibrillation investigators [AFI]) to 0.72 (CHA₂DS₂‐VASc). The CHADS₂ and CHA₂DS₂‐VASc schemes having the best c‐statistics (0.717 and 0.724, respectively) with significant discriminating value between risk strata (both P < 0.001). The proportion of patients assigned to individual risk categories varied widely across the schema, with those categorized as “moderate‐risk” ranging from 5.3% (CHA₂DS₂‐VASc) to 49.2% (CHADS₂‐classical). Conclusion: In this “real world” cohort, current published risk schemas have modest predictive ability, with the CHADS₂ and CHA₂DS₂‐VASc schemes having the best predictive value for thromboembolism. Future trials could assess the value of alternative strategies for thromboprophylaxis in high‐risk anticoagulated patients identified by these schemes. (J Cardiovasc Electrophysiol, Vol. 22, pp. 25‐30, January 2011)     

Effect of age on 3 year outcome in early rheumatoid arthritis

OBJECTIVE: To investigate the effect of age on clinical and radiological outcome and on efficacy and tolerance of antirheumatic therapy in early rheumatoid arthritis (RA). METHODS: In a prospective 3 year study 113 patients (83 women, 30 men) were divided into 2 groups according to age at onset of disease: before (n = 55) and after 55 years of age (n = 58). For clinical outcome, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, Ritchie index, and number of swollen joints were measured. Radiological progression was analyzed by Larsen score. The principles of the "sawtooth" strategy were applied in the treatment of all patients. RESULTS: At baseline, inflammatory activity (ESR, CRP) and the Larsen score for hands were significantly higher in patients with late onset RA (LORA) and they also developed more extraarticular symptoms compared to patients with early onset RA (EORA). However, no differences were found in Ritchie index, number of swollen joints, or CRP values between the groups. Also during the followup there was a trend toward increased inflammatory activity (ESR) among LORA patients. After the initiation of antirheumatic therapy a parallel improvement in clinical activity was observed in the 2 groups. The frequencies of remissions, side effects, and withdrawals due to drug inefficacy did not differ significantly between the 2 groups. The radiological progression was also comparable. CONCLUSION: The onset of RA was more active in patients with LORA. However, the clinical course and the radiological progression were parallel in LORA and EORA patients. The "sawtooth" therapy was equally tolerated in both patient groups.     

The “worth” of routine spirometry in a cystic fibrosis clinic

In our cystic fibrosis clinic, all patients older than 6 years perform spirometry at each visit just before being seen by the health care team. Upon review, we determined that our perceived rationale for this practice was that the medical history fails to detect deterioration in a sizable minority of patients whose pulmonary decline can be detected by spirometry. Furthermore, the literature and our own experience indicates that physical examination frequently will not detect changes in pulmonary status until the changes are advanced. As part of an ongoing quality/cost assessment, we decided to challenge our rationale for performing routine spirometry. Using standard methodology, we developed a six-item Likert style questionnaire, the purpose of which was to assess perceived changes in pulmonary symptoms since the last clinic visit. The questionnaire had an acceptable degree of internal consistency (Cronbach's alpha = 0.92), although the question about sputum production showed the least correlation with responses to other items. We administered the questionnaire to 103 consecutive different patients and examined the association between reported changes in symptoms and actual changes in spirometric outcomes. Overall, there was a statistically significant, but clinically weak association between symptom scores and change in FEV₁, r² = 0.16, P < 0.001. Twenty-three patients had a decline in FEV₁ of ⩾10% from one clinic visit to the next. Depending on the method used to place symptom scores into categories indicating that pulmonary symptoms were “worse,” “same,” or “better” than at the last clinic visit, 40–60% of these 23 patients indicated they felt the “same” or “better.” We conclude that spirometry is a justifiable part of all clinic visits for patients with cystic fibrosis, assuming that one would want to detect and treat declines in pulmonary status before they become advanced. Pediatr Pulmonol. 1998; 25:231–237. © 1998 Wiley-Liss, Inc.     

A 15-year follow-up study on the outcome in patients with early rheumatoid arthritis

This study aimed to investigate the natural course of early rheumatoid arthritis (RA) after treatment for 15 years based on the present data of patients who had been enrolled in a 1 year study of early RA conducted by the Japan Rheumatism Foundation in 1981 and 1982. An examination form was mailed to each doctor who had participated in the previous study requesting them to record the present data of the patients. The patients were requested to fill out the AIMS2 questionnaire. Patients had been randomly assigned into three treatment groups: those treated with gold, with d-penicillamine and without slow acting antirheumatic drugs (SAARDs). Information was obtained concerning 74 of 161 patients who had completed the previous 1 year study. Clinical remission was observed in 20 of 74 patients. The current status of RA by physician’s assessment was reported to be well controlled in 32 of 48 cases (66.7%); however, no remarkable improvement was seen in erythrocyte sedimentation rate (ESR, and the number of painful joints compared with the values at entry 15 years previously. Radiographical stages showed progression and the average score of AIMS2 had deteriorated in most cases. High ESR, progression of joint damage and positive rheumatoid factors at the early stage of RA were suggested to be factors relating to QOL deterioration. These results suggest that it would be difficult to modify the natural course of RA by currently used treatment strategies with SAARDs.     

Iron Metabolism and “Sports Anemia”

Abstract Several reports have suggested that iron deficiency might explain “sports anemia” especially in long distance runners. The present study was made to further study the iron metabolism in runners as the proposed cause of “sports anemia” is abstruse considering the good iron nutrition in these athletes. Based on a screening of 43 elite male runners, using bone marrow hemosiderin, serum ferritin and transferrin saturation, two groups of subjects were selected for a very extensive study on iron metabolism. In group 1 (n=5) iron depletion was suggested in at least one of the screening studies. In group 2 (n=7) at least one test strongly indicated good iron repletion. This experimental design was chosen to obtain two groups with similar body composition and exercise load but different iron metabolism. The studies comprised determinations of red cell and plasma volumes, plasma iron turnover and red cell incorporation of radioiron, red cell indices, plasma iron and transferrin, red cell protoporphyrin, serum ferritin, serum haptoglobin, urinary iron losses, iron absorption, bone marrow hemosiderin, dietary intake of energy and nutrients and a Desferal test. Pooling the results together it was obvious that none of the subjects were truly iron-deficient. A few occasional findings suggesting low iron stores cannot be satisfactorily explained and indicate that further studies are needed